The "Hepatic core": how to reach it

The "hepatic core" has to be considered a zone inside the hepatic parenchyma where different liver segments converge

Chemical Characterization and Cytotoxic and Antioxidant Activity Evaluation of the Ethanol Extract from the Bulbs of Pancratium maritimun Collected in Sicily

P. maritimum L., belonging to the Amaryllidaceae family, is a species that grows on beaches and coastal sand dunes mainly on both sides of the Mediterranean Sea and Black Sea, the Middle East, and up to the Caucasus region. It has been largely investigated due to its several interesting biological properties. With the aim of providing new insights into the phytochemistry and pharmacology of this species, the ethanolic extract of the bulbs from a local accession, not previously studied, growing in Sicily (Italy), was investigated. This chemical analysis, performed by mono- and bi-dimensional NMR spectroscopy, as well as LC-DAD-MSn, allowed to identify several alkaloids, three of which were never detected in the genus Pancratium. Furthermore, the cytotoxicity of the preparation was assessed in differentiated human Caco-2 intestinal cells by trypan blue exclusion assay, and its antioxidant potential was evaluated using the DCFH-DA radical scavenging method. The results obtained demonstrate that P. maritimum bulbs’ extract exerts no cytotoxic effect and is able to remove free radicals at all the concentrations tested

Contribution of 18 F-FDG PET/CT in the Staging of Pancreatic Solid Pseudopapillary Neoplasms: A Case Report

: Solid pseudopapillary neoplasm (SPN) is an extremely rare pancreatic epithelial neoplasm with low malignancy that affects mainly young females. It is characterized by a good prognosis, even in the presence of metastases. SPNs have a particular avidity for 18F-fluorodeoxyglucose (18F-FDG). Nonetheless, there are very few papers in the literature on the use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F- FDG PET/CT) in the diagnosis and staging of SPNs. A 23-year-old woman presented to our attention with gastric outlet obstruction due to a bulky solid pseudopapillary neoplasm of the pancreatic head. A 18F-FDG PET/CT showed a marked 18F-FDG uptake at the pancreatic head with no abnormal metabolic activity in other abdominal organs. Given the particular avidity for 18F-FDG, SPNs can be easily recognized on 18F-FDG PET/CT. However, this exam is not useful in differentiating this neoplasm from other malignant pancreatic solid lesions, but it could give a contribution to the staging by the ability to identify potential metastases or recurrences

T-Cell Lymphoblastic Lymphoma Arising in the Setting of Myeloid/Lymphoid Neoplasms with Eosinophilia: LMO2 Immunohistochemistry as a Potentially Useful Diagnostic Marker

Simple Summary Rarely, T-lymphoblastic lymphoma (T-LBL) may develop in the setting of myeloid/lymphoid neoplasms with eosinophilia. Given important therapeutic implications, it is crucial to identify T-LBL arising in this particular context. LIM domain only 2 (LMO2) is known to be overexpressed in almost all sporadic T-LBL and not in immature TdT-positive T-cells in the thymus and in indolent T-lymphoblastic proliferations. We retrospectively evaluated the clinical, morphological, immunohistochemical and molecular features of 11 cases of T-LBL occurring in the setting of myeloid/lymphoid neoplasms with eosinophilia and investigated the immunohistochemical expression of LMO2 in this setting of T-LBL. Interestingly, 9/11 cases were LMO2 negative, with only 2 cases showing partial expression. In our study, we would suggest that LMO2 immunostaining, as part of the diagnostic panel for T-LBL, may represent a useful marker to identify T-LBL developing in the context of myeloid/lymphoid neoplasms with eosinophilia. Background: Rarely, T-lymphoblastic lymphoma (T-LBL) may develop in the setting of myeloid/lymphoid neoplasms with eosinophilia (M/LNs-Eo), a group of diseases with gene fusion resulting in overexpression of an aberrant tyrosine kinase or cytokine receptor. The correct identification of this category has relevant therapeutic implications. LIM domain only 2 (LMO2) is overexpressed in most T-LBL, but not in immature TdT-positive T-cells in the thymus and in indolent T-lymphoblastic proliferations (iT-LBP). Methods and Results: We retrospectively evaluated 11 cases of T-LBL occurring in the context of M/LNs-Eo. Clinical, histological, immunohistochemical and molecular features were collected and LMO2 immunohistochemical staining was performed. The critical re-evaluation of these cases confirmed the diagnosis of T-LBL with morphological, immunohistochemical and molecular features consistent with T-LBL occurring in M/LNs-Eo. Interestingly, LMO2 immunohistochemical analysis was negative in 9/11 cases, whereas only 2 cases revealed a partial LMO2 expression with a moderate and low degree of intensity, respectively. Conclusions: LMO2 may represent a potentially useful marker to identify T-LBL developing in the context of M/LNs-Eo. In this setting, T-LBL shows LMO2 immunohistochemical profile overlapping with cortical thymocytes and iT-LBP, possibly reflecting different molecular patterns involved in the pathogenesis of T-LBL arising in the setting of M/LNs-Eo

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study : a WSES observational study

BackgroundTiming and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.MethodsThis worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.ResultsA total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate >= 22 breaths/min, systolic blood pressure 4mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.ConclusionsThe simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.Peer reviewe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Colite acuta da raggi dopo radioterapia preoperatoria short-course per il cancro del retto: uno studio morfologico, immunoistochimico e genetico

Background: La radioterapia preoperatoria con o senza chemioterapia si è dimostrata utile nel ridurre i tassi di recidiva locale e nel migliorare la sopravvivenza globale nel cancro del retto. I cambiamenti indotti dalle radiazioni nel tumore sono ben descritti, mentre è stata prestata meno attenzione agli effetti delle stesse nella mucosa non neoplastica. Il nostro scopo è fornire un'analisi dettagliata delle caratteristiche morfologiche, immunoistochimiche e genetiche presenti nella mucosa non neoplastica. E’ necessario che i patologi acquisiscano familiarità con le suddette caratteristiche morfologiche, quando valutano campioni di cancro del retto di pazienti trattati con radioterapia preoperatoria, in particolare con schema short-course, al fine di evitare diagnosi errate. Metodi e risultati: Abbiamo confrontato 2 gruppi di 95 pazienti con cancro del retto trattati con radioterapia preoperatoria short-course (25 Gy somministrati in 5 giorni consecutivi, seguiti da intervento chirurgico pochi giorni dopo; 45 pazienti) o radioterapia long-course (45-50 Gy in 4-6 settimane, seguito da intervento chirurgico 4 settimane dopo; 50 pazienti). A seconda del tipo di protocollo, sono state osservate diverse caratteristiche istopatologiche, in termini di infiammazione, anomalie ghiandolari e differenziazione endocrina nella mucosa non neoplastica all'interno del volume irradiato. Da notare che le caratteristiche che imitano la displasia come la distorsione della cripta, l'atipia nucleare e citoplasmatica dell'epitelio ghiandolare, sono state identificate solo nel gruppo short-course. L'analisi della mutazione del DNA, utilizzando un pannello di 56 geni frequentemente mutati nel cancro del colon-retto, e l'immunocolorazione con p53 sono state eseguite sia su mucosa neoplastica che su mucosa non neoplastica e danneggiata da radiazioni in un sottogruppo di pazienti short-course. Mutazioni somatiche sono state identificate solo nella mucosa neoplastica, supportando il concetto che i tessuti con caratteristiche "displasiche" indotte dalle radiazioni non sono geneticamente trasformati. Conclusioni: I patologi dovrebbero essere consapevoli dei caratteristici cambiamenti morfologici indotti dalle radiazioni. La presenza di caratteristiche che simulano la displasia nel gruppo trattato con radioterapia short-course può portare a gravi errori diagnostici, se interpretata erroneamente. L'analisi NGS ha ulteriormente convalidato il concetto morfologico secondo cui le anomalie indotte dalle radiazioni non rappresentano lesioni pre-neoplastiche.Background: Preoperative radiotherapy with or without chemotherapy has been demonstrated of value in reducing local recurrence rates and improving overall survival in rectal cancer. Radiation-induced changes in the tumor are well described, whereas less attention has been given to the non-neoplastic mucosa. Our aim is to provide a detailed analysis of morphological, immunohistochemical and genetic features present in non-neoplastic mucosa. Pathologists need to be familiar with aforementioned morphological features, when evaluating rectal cancer specimens of patients preoperatively treated with radiotherapy, especially with short-course regimen, in order to avoid misdiagnosis. Methods and Results: We compared 2 groups of 95 rectal cancer patients treated preoperatively with either short-course (25 Gy administered in 5 consecutive days, followed by surgery a few days after; 45 patients) or long-course radiotherapy (45-50 Gy in 4-6 weeks, followed by surgery 4 weeks later; 50 patients). Depending on the type of protocol, different histopathological features, in terms of inflammation, glandular abnormalities and endocrine differentiation were seen in the non-neoplastic mucosa within the irradiated volume. Of note, features mimicking dysplasia, such as crypt distortion, nuclear and cytoplasmic atypia of glandular epithelium, were identified only in the short-course group. DNA mutation analysis, using a panel of 56 genes frequently mutated in colorectal cancer, and p53 immunostaining were performed on both neoplastic and radiation-damaged non-neoplastic mucosa in a subset of short-course cases. Somatic mutations were identified only in neoplastic mucosa, supporting the concept that tissues with radiation-induced “dysplastic-like” features are not genetically transformed. Conclusions: Pathologists should be aware of the characteristic morphological changes induced by radiation. The presence of features simulating dysplasia in the group treated with short-course radiotherapy may lead to serious diagnostic mistakes, if erroneously interpreted. NGS analysis further validated the morphological concept that radiation-induced abnormalities do not represent pre-neoplastic lesions

Re: Anatomy of hepatic lymphatics and its implications in hepatic malignancies

We read with interest the article by Yong et al.1 concerning the lymphatics of the liver and its pedicle